Jeffrey M. Weinberger

Selective endovascular embolization for refractory idiopathic epistaxis is a safe and effective therapeutic option: technique, complications, and outcomes.

Epistaxis generally responds to conservative management, but a more invasive approach, such as superselective embolization, is sometimes justified. We report our experience with endovascular procedures in 19 patients from 2002 to 2011 for the treatment of refractory idiopatic posterior epistaxis. The sphenopalatine artery and distal internal maxillary arteries were embolized in all patients. Unilateral embolization was performed in 12 patients (63%), bilateral embolization in seven (37%). Additional embolization of the descending palatine artery was performed in eight patients (42%) and embolization of the facial artery and palatine arteries in four (21%). In one patient the distal ophthalmic artery was embolized with n-butyl cyanoacrylate. No minor or major complications occurred in relation to the embolization procedures. The average hospital stay was 11.1±8.6 days, including an average 5.2±3.4 days after embolization. Average follow-up after discharge was 21.3±25.7 months. Superselective endovascular embolization proved safe and effective in controlling idiopathic epistaxis, refractory to other maneuvers.

Furosemide administered before noise exposure can protect the ear.

Objectives We assessed the effect of furosemide administration on noise-induced hearing loss. This drug reversibly elevates the auditory threshold by inducing a temporary reduction of the endocochlear potential and thereby suppresses the cochlear amplifier and active cochlear mechanics. Methods Mice were given a single injection of furosemide 30 minutes before exposure to 113 dB sound pressure level broadband noise. Control animals received saline solution. Furosemide was administered in other mice after the noise exposure. Auditory threshold shifts were assessed by recording auditory nerve brain stem evoked response (ABR) thresholds to broadband clicks. Results The mean ABR threshold in the group injected with furosemide and exposed to temporary threshold shift (TTS)-producing noise was elevated by 20.4 ± 12.3 dB, and that in the saline control group was elevated by 35.4 ± 18.3 dB (p < 0.02). The mean threshold elevations in the group injected with furosemide and exposed to permanent threshold shift (PTS)-producing noise and in the PTS saline control group were 15.0 ± 10.3 dB and 27.0 ± 12.7 dB, respectively (p < 0.01). Similar results were obtained when the PTS was assessed with an 8-kHz tone burst ABR. There was no significant difference in the PTS between mice given a single injection of furosemide and those given saline solution after the noise; this finding shows that furosemide is not acting as an antioxidant. Conclusions It appears that reversible hearing threshold elevation as a result of furosemide administration before noise exposure can reduce the TTS and PTS. This finding provides insight into the mechanism of noise-induced hearing loss.

Airway obstruction and Hemophilia‐A: Epiglottis hematoma

Acute upper airway obstruction is a potentially life‐threatening event. Hemophilia‐A is a coagulopathy with high risk for spontaneous bleeding. Here we describe for the first time a spontaneous epiglottic internal hemorrhage leading to upper airway narrowing in a hemophilia‐A patient. The patient was admitted to the intensive care unit for airway observation and treatment with factor VIII supplementation. In the first 48 hours there was rapid respiratory improvement. The epiglottic swelling resolved on the 5th day. In this patient no oral intubation or surgical management was needed. Laryngoscope, 2010

Clinicopathologic Features and Outcome of the Oncocytic Variant of Papillary Thyroid Carcinoma

Objectives: The purpose of this study was to define the clinicopathologic features and outcome of the oncocytic variant of papillary thyroid carcinoma (OVPTC) with a review of the literature. Methods: Twenty-three patients with OVPTC over a 10-year period were studied. Demographic, clinical, and histopathologic features and outcome data were analyzed retrospectively. Results: Seventeen women and 6 men, ages ranging from 20 to 76 years (95% confidence interval, 43.0 to 54.48), were studied. Cervical lymph node involvement was found in 43.4% of the patients. Most of the recurrences were associated with thyroid masses greater than 2 cm in diameter. Evaluation of the overall survival data by the Kaplan-Meier method revealed that most recurrences took place earlier than 30 months, and the majority of patients (74%) were well, with no evidence of disease, up to 78 months after the last treatment. All of the OVPTC cases presented as nonencapsulated tumors, and 78.2% demonstrated extrathyroid stromal invasion. Conclusions: OVPTC is a unique variant of papillary thyroid carcinoma that has distinctive clinicopathologic features. Since OVPTC is often associated with local invasion and may involve cervical lymph nodes, it may require more extensive surgery than classic papillary thyroid carcinoma.

Effects of furosemide on the hearing loss induced by impulse noise

BackgroundThe permanent hearing loss following exposure to intense noise can be due either to mechanical structural damage (tearing) caused directly by the noise or to metabolic (biochemical) damage resulting from the elevated levels of free radicals released during transduction of the sound overstimulation. Drugs which depress active cochlear mechanics (e.g. furosemide and salicylic acid) or anti-oxidants (which counteract the free radicals) are effective in reducing the threshold shift (TS) following broadband continuous noise. This study was designed to determine whether furosemide can reduce the TS following exposure to impulse noise, similar to its action with continuous broadband noise.MethodsShortly after furosemide injection, mice were exposed to simulated M16 rifle impulse noise produced by different loudspeakers and amplifiers in different exposure settings and, in other experiments, also to actual M16 rifle shots.ResultsDepending on the paradigm, the simulated noises either did not produce a TS, or the TS was reduced by furosemide. The drug was not effective in reducing TS resulting from actual impulse noise.ConclusionSimulated M16 rifle impulse noise may not truly replicate the rapid rise time and very high intensity of actual rifle shots so that the TS following exposure to such noise can be reduced by these drugs. On the other hand, actual M16 impulse noise probably causes direct (frank) mechanical damage, which is not reduced by these drugs.

Candida epiglottitis: A rare emergent condition — Appearance, treatment and pitfalls

A 50-year-old man arrived at the emergency room with a two month history of gradually worsening symptoms of sore throat, hoarseness, dyspnea, and dysphagia. In the 2days prior to admission the upper airway obstruction progressed to frank inspiratory stridor and, in addition. No lymphadenopathy of the neck was noted. He had a history of heavy smoking. Examination revealed an erythematous and swollen epiglottis and supraglottis. Vocal cords and subglottis were normal. He was found to have a white blood cell count of 8600/mm with 56.8% neutrophils. A broad spectrum antibiotic was initiated as well as systemic and inhaled steroids. Because of the two month history of evolving symptoms and with the background of heavy smoking, an “acute on chronic” condition was suspected, likely a malignancy complicated by an acute bacterial infection. In the first 24h there was rapid respiratory deterioration with severe swelling of the supraglottis and an attempt at intubation failed necessitating an emergent crico-thyrotomy. There was significant

Extraction of a headscarf pin from the vertebral artery without embolization

Foreign bodies traversing the aerodigestive tract lining into the surrounding soft tissues is a well‐known entity. A 14‐year‐old girl was referred to our hospital after swallowing a pin that was not visualized by laryngoscopy, despite a neck film that localized it to the level of the larynx.

Is Surgery for an FNA proven Warthin's Tumor Passé?

Abstract Background: Warthin tumor is a common benign salivary gland lesion. Its optimal treatment mode is controversial. We analyze the accuracy of Warthin tumor pre-operative fine-needle aspiration (FNA)-based

Thyroidectomy Practice After Implementation of the 2015 American Thyroid Association Guidelines on Surgical Options for Patients With Well-Differentiated Thyroid Carcinoma

Importance The recommended extent of surgery for well-differentiated thyroid carcinoma has been modified considerably in the updated 2015 American Thyroid Association guidelines published in January 2016. To date, the changes in clinical practice after publication of these new guidelines have not been demonstrated. Objective The aim of this study was to evaluate clinical practice changes associated with implementation of the updated guidelines on the surgical procedure rates of total thyroidectomy, thyroid lobectomy, and completion thyroidectomy at a single tertiary medical center. Design, Setting, and Participants This is a retrospective cohort study of 169 patients at the Hadassah–Hebrew University Medical Center, Jerusalem, Israel. Patients with pathologically proved, well-differentiated thyroid carcinoma who underwent surgery between January 1, 2013, and December 31, 2014, were compared with patients who underwent surgery from January 1 to December 31, 2016. A total of 434 thyroidectomy procedures were performed during the study period, and 251 had pathologically proved, well-differentiated thyroid carcinoma. Patients with tumors larger than 4 cm, involved lymph nodes, or bilateral nodules were excluded. Main Outcomes and Measures Primary outcomes were the rate of up-front total thyroidectomy vs lobectomy and the rates of completion thyroidectomy before and after the implementation of the new guidelines. Results Of the 169 patients in the final analysis, 118 (69.8%) were included from 2013 to 2014 and 51 (30.2%) in 2016. The mean (SD) age for the entire cohort was 44 (13.8) years, and 129 (76.3%) were women. Up-front total thyroidectomy was performed in 72 of 118 patients (61.0%) prior to the 2015 American Thyroid Association guidelines and 16 of 51 (31.4%) following their implementation (odds ratio, 0.29; 95% CI, 0.14-0.59). The rate of completion thyroidectomy also significantly decreased between these periods (73.9% vs 20.0%; odds ratio, 0.09; 95% CI, 0.04-0.19). Conclusions and Relevance The updated 2015 American Thyroid Association guidelines implementation was associated with a significant decrease in the rates of both up-front total thyroidectomy and completion thyroidectomy. According to these findings, only 1 of 5 patients who undergoes thyroid lobectomy will require a completion procedure.

Is That a Fish Bone

Background: Impacted foreign bodies in the esophagus can easily cause mucosal ulceration, inflammation and infections which may result in various fatal complications. Computed tomography was determined to be very useful in the diagnosis of impacted fish bones in the esophagus. Aim: Demonstrate incorrect imaging interpretation as result of enteric opacification following oral administration of medications. Case presentation: A seventy-seven year old woman was referred regarding odynophagia after eating fish. A computed tomography scan of the neck and chest showed a 5 cm long bone in the upper esophagus. However, rigid esophagoscopy failed to identify a bone. Amiodarone is fat-soluble iodine rich antiarrhythmic agent. In our case the high iodine content of amiodarone caused the deceptive computed tomography scan. Conclusion: Medications’ radio-opacification may confuse the physician while searching for foreign bodies.